Panelists: Must Coordinate Insurance Coverage, Behavioral Healthcare

Experts: Bridging gap requires better cooperation and communication between insurer and providers and with patients about mental-health and addiction services

Ann O’Grady, clinical director of Beacon Health Options, and Barbara Johnston, director of advocacy and policy for the Mental Health Association in New Jersey, take part in panel discussion of how to better coordinate insurance coverage, behavioral healthcare, and patient outreach.

Not enough New Jerseyans who need treatment for mental illnesses and addiction are receiving adequate and timely help.

But the situation could improve drastically if healthcare providers and insurers work together more effectively to reach patients, according to experts examining the issue.

Federal officials estimate that only 37.9 percent of those with illnesses receive any treatment annually.

Policy and industry experts discussed these issues and potential solutions at a recent conference hosted by The Sentinel Project, which seeks to make sure that people with insurance get healthcare they’re entitled to, and Seton Hall University School of Law’s Center for Health & Pharmaceutical Law & Policy. The Robert Wood Johnson Foundation funded the conference.

The issue could also become crucial for state government as it seeks to improve the health of patients receiving Medicaid -- the Rutgers Center for State Health Policy found 81 percent of Medicaid patients who make frequent visits to hospitals have behavioral health issues, a term that covers both mental health and addiction .

While insurance and provider groups have blamed each other for creating unnecessary roadblocks to coverage, representatives of both sides on hand at the conference said they are trying to improve coordination and remove obstacles to care.

The effect on patients who go untreated serves as a drag on the state’s economy, according to John Sarno, president of the Employer’s Association of New Jersey, an organization that provides legal advice to employers and links them with insurance providers.

The outdated directories of providers listed on insurers’ websites are another stumbling block.

The MHANJ’s director of advocacy and policy, Barbara Johnston, said it’s essential that people seek treatment as soon as possible, and that insurers make sure that patients know they can use a provider outside the insurers’ network if they aren’t able to find an in-network provider.

“I think it’s an area that needs to be communicated more widely, so that consumers don’t get discouraged if they can’t find a network provider early on,” Johnston said. “They shouldn’t give up and they should make sure that they contact plans if they are unsuccessful in finding a provider.”

Johnston also said that insurers should more prominently advertise their own services that connect residents with providers.

“Mental health is the only area, really the only disease state … where we wait until there’s a crisis before we treat somebody,” she said.

A major project to find out exactly when mental-health patients run into roadblocks in receiving services is being planned by five South Jersey hospital systems: Cooper Health, Inspira Health Network, Kennedy Health, Lourdes Health System and Virtua. They’ve formed the South Jersey Behavioral Health Innovation Collaborative, which will be studying exactly when individuals run into problems, with the goal of developing pilot projects to remove these barriers. The Camden Coalition of Healthcare Providers and the New Jersey Hospital Association are aiding the effort.

Camden Coalition general counsel and director of external affairs Mark Humowiecki said hospitals could save money and patients receive better care if patients received outpatient treatment before they needed to visit hospitals.

“Where’s the rub here?” is the question the study will seek to answer, he said. “We all agree there’s a lack of services out there for people that need it.”

Many new patients are eligible to receive behavioral health services thanks to two federal laws – the Mental Health Parity and Addiction Equity Act of 2008 and the Affordable Care Act of 2010. The first law required insurers to offer mental-health and addiction services coverage equal coverage to that provided for other healthcare, while the second law expanded the number of people with insurance and required most individual and small-group plans to cover mental-health and addiction services.

New Jersey Association of Health Plans President Wardell Sanders noted that insurers depend on having an adequate supply of providers, and that New Jersey has particularly acute problems with the number of inpatient behavioral health treatment beds, psychiatrists, and behavioral-health specialists for children.

“The supply isn’t there,” Sanders said.

He also noted that some providers are choosing to remain outside of insurance networks, in same cases charging large sums that insurers will ultimately be required to pay. There’s an ongoing debate in Trenton over out-of-network billing.

Ann O’Grady, clinical director of Beacon Health Options, a company that’s been hired by Horizon Behavioral Health to help manage cases, said Horizon has made a significant investment in identifying mental-health providers who can serve its members, and in following up to ensure that people are receiving treatment.

Horizon is also using real-time claims data to quickly identify patients who are making frequent hospital visits and to connect them with behavioral health providers.

“We are much more successful where we’re able to call the member” when they are still in a hospital room or primary care provider office, O’Grady said. These patients “are much more receptive to continuing to work with us when they leave.”

Finding providers -- and coordinating insurance coverage -- is particularly important for patient when they move between inpatient hospital treatment and outpatient treatment. For example, if a patient who had an overdose doesn’t have an appointment for treatment soon after leaving a hospital, they may relapse.

The Carrier Clinic, an inpatient, residential and outpatient provider in Montgomery Township, works on a plan for what care patients will receive when they’re discharged from the moment they enter the door, said Trish Toole, clinic vice president. When insurers turn down coverage that clinic staff believe patients should receive, they’ve been appealing the decisions to the state Department of Banking and Insurance.

But clinic staff members have been disappointed by the lack of engagement with patients’ primary-care providers, who sometimes don’t even return phone calls. Toole said a potential solution is the expansion of “medical homes” – which bring behavioral healthcare providers together with medical providers in the same practice and ensure that patients receive well-coordinated care, Toole said.

Providers voiced concern that insurers have been squeezing them with low reimbursements. Social worker Phillip Yucht, who directs a group practice and is president of a national billing business, said the reason he doesn’t join insurance networks is the low reimbursements. He added that new marketplace insurance plans under the Affordable Care Act require significant out-of-pocket costs for patients, which can also serve as a barrier to seeking services.

Robert Budsock, president and CEO of Newark addiction treatment provider Integrity House, also said the hurdles to finding inpatient treatment for patients are significant, with insurers requiring that patients to have undergone a variety of terrible experiences before they’ll approve coverage. He recalled a recent conversation with the CEO of a major New Jersey company (who he didn’t name) who had difficulty finding appropriate treatment for a brother who was dealing with depression and alcoholism.

“Here’s someone who is insured, has great insurance, is well-connected and he was having difficulty moving his brother from point A to point B to make sure he’s continuing to get the treatment that he needs,” Budsock said.